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251
 252 FRATES AND LAING AJR:165, August 1995
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For a woman with a positive pregnancy test and no identi- when the mean sac diameter is 8 mm (gestational age of 5.5
fiable intrauterine gestational sac, one of three diagnoses is weeks). Cardiac activity should be detected when the mean
possible: an early intrauterine pregnancy that is too small for sac diameter is 16 mm (gestational age of 6.5 weeks) [14] and
sonographic identification, a recent spontaneous abortion, or often is appreciated by a gestational age of 6.0 weeks. The
an EP. In this situation, quantitative analysis of the serum classically described double decidual sac sign of a normal
beta-human chorionic gonadotropin (-hCG) level may pro- intrauterine pregnancy seen on transabdominal imaging [15]
vide useful information. Trophoblastic tissue produces -hCG becomes less critical with the transvaginal approach, as inter-
8 days after conception [12], with a normal doubling period of nal contents of the sac often are recognizable with vaginal
approximately 48 hr. In a normal pregnancy, an intrauterine scanning before the double decidual sac sign can be appreci-
gestational sac should be seen by transvaginal sonography ated. When an intrauterine fluid collection that is not recogniz-
with a 3-hCG value of 1000 mlU/ml (International Reference able as a normal gestational sac is present, diagnostic
Preparation [IRP]) or higher [13]. If the second International considerations include an abnormal intrauterine pregnancy or
Standard (IS) is used, the corresponding discriminatory a pseudosac in association with an EP.
value is approximately 500 mIU/mI, with 1 mlU/mI (IRP) With careful transvaginal scanning, it is almost always pos-
equaling approximately 2 mIU/mI (second IS). Because of sible to distinguish a normal early intrauterine pregnancy from
possible confusion when switching standards, it is best to a pseudosac. An early gestational sac is round and is located
use the same laboratory for serial measurements. It is also within the decidua, as opposed to within the endometrial cay-
crucial to know which standard is being used. In a clinically ity [16, 17] (Fig. 1). This knowledge may help differentiate an
stable patient whose 3-hCG level is lower than the discrimi- early normal gestational sac that does not yet contain a yolk
natory value of 1000 mlU/mI (IRP), the possibility of an early sac or an embryo from the pseudosac of an EP. Pseudosacs
normal intrauterine pregnancy remains, and serial quantita- have been reported in 5-10% of patients with EP and result
tive -hCG determinations as well as sonographic follow-up from a prominent decidual reaction surrounding centrally
are recommended. If no sac is visible with a -hCG value located endometrial fluid [6, 18] (Fig. 2A). A pseudosac is typ-
above 1000 mlU/ml, a careful history often can determine ically elongated or oval and most often has irregular margins
whether products of conception may have been passed. and only minimal surrounding echoes. On occasion, it may
When the history is negative in this regard, the likelihood of have a smooth, regular margin that is thick and echogenic. A
an EP is high. pseudosac may contain internal debris that sonographically
resembles embryonic tissue (Fig. 2B).
Sonographic Findings In contrast, it may be difficult or impossible to differentiate
a pseudosac from an abnormal intrauterine gestational sac.
Uterus In such cases, uterine dilatation and curettage can be both
The initial transvaginal examination of the uterus in a patient diagnostic and therapeutic. Retrieval of chorionic villi con-
at risk for EP most often reveals an intrauterine pregnancy. firms an intrauterine pregnancy, whereas their absence sug-
Under normal circumstances, a yolk sac should be visible gests an EP.

A B
Fig. 1 .-Transvaglnal sonogram of 33-year- Fig. 2.-Intrauterine pseudogestatlonal sac found in association with ectopic pregnancies in two
old patient with normal Intrauterine pregnancy. patients. Sonographic appearance of pseudogestational sac Is variable.
Longitudinal sonogram of uterus shows in- A, Coronal sonogram of uterus shows central pseudogestational sac with slightly irregular,
tradecidual location of normal 5-week intrauter- echogenic margins.
ine pregnancy, outlined by small amount of fluid B, Sonogram for another patient shows complex intrauterIne fluid collection with Internal debris.
in endometrial cavity. ThIs pseudogestational sac mimics abnormal Intrauterine pregnancy.
 AJR:165, August 1995 SONOGRAPHIC EVALUATION OF ECTOPIC PREGNANCY 253
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Tiny, well-defined fluid collections within the endometrium [21] and is characterized by an anechoic center and an
(termed decidual cysts) are occasionally visible during trans- echogenic periphery (Fig. 4). In some patients, the ring con-
vaginal sonography, and a recent study suggests that they tains a fetal pole or yolk sac. In 8-25% of patients with a
may be an indicator of EP [1 9]. However, this retrospective tubal ring, cardiac activity can be detected [21-25] (Fig. 5).
analysis differs from our own experience, as we have Occasionally, echogenic material attributable to blood or
detected similar cysts in nonpregnant patients and have ectopic trophoblastic tissue may be localized clearly within a
seen early normal pregnancies that resemble cysts (Fig. 3). dilated fallopian tube (Fig. 6). A complex mass with mixed
We look forward to future studies to confirm or refute the echogenicity and poorly defined borders also is highly sug-
diagnostic value of decidual cysts. gestive of a hematoma and/or ectopic trophoblastic tissue. In
this instance, meticulous sonographic scanning can some-
times confirm the diagnosis of EP by revealing an adnexal
Adnexa
ring within the mass (Fig. 7).
For localization of an EP by transvaginal sonography, the The adnexal mass of an EP may be quite subtle because
ovary should be identified and used as an anatomic landmark. of its small size. This is a particular problem in patients who
The ovary is typically positioned anteriorly and medial to the conceive after treatment for infertility, because sonography
iliac vessels. In most patients, it is located near the ampullary often is performed at a gestational age of 5-6 weeks. Early
portion of the fallopian tube, which is the most frequent site of scanning may even lead to the detection of an EP before
ectopic implantation [20]. Once the ovary has been identified, symptoms develop. For demonstration of subtle abnormali-
the surrounding tissues should be meticulously scanned in an ties such as tiny tubal rings, optimal scanning technique is
effort to detect an extraovarian mass or ringlike structure required. It may be beneficial to enlarge a suspicious area
attributable to an EP within the fallopian tube. An abnormal through high-resolution computer processing. Follow-up
mass can be distinguished easily from bowel by the absence examinations should be performed to clarify any question-
of peristalsis. Steady pressure from the examiner’s nonscan- able findings. Serial -HCG determinations also may be
ning hand on the patient’s low anterior abdominal wall may helpful in this patient population.
help compress overlying bowel gas that could obscure a The identification of a simple ovarian cyst should not raise
mass. The vaginal probe also can be used to determine the the possibility of an EP, as the cyst is usually the corpus
site of maximum tenderness, which frequently corresponds to luteum. A complex intraovarian lesion also is unlikely to rep-
the location of the EP. Although most EPs are located resent an EP, as true ovarian pregnancies constitute fewer
between the ovary and the uterus, they may implant anywhere than 1% of all EPs [26]. The location of an ovarian cyst (right
in the pelvis, and it may be necessary to extend the examina- versus left) will not aid in localizing the side of the EP, as con-
tion to include the regions adjacent to the uterine fundus, the tralateral implantation occurs in up to one third of cases [27].
cul-de-sac, and the lateral margins ofthe pelvis. The lithotomy The accuracy of transvaginal sonography in diagnosing
position should be used for transvaginal scanning, as it allows EP varies considerably, in part because of the wide range of
improved visualization of the anterior and lateral aspects of criteria used to make the diagnosis [13, 21, 22, 25, 28]. The
the pelvis. If transvaginal sonography fails to identify an EP, most strict criterion, with the highest specificity (100%) but
the addition of transabdominal scanning with a distended the lowest sensitivity (15-20%), is the identification of an
bladder should be considered. extrauterine gestational sac that contains a yolk sac or an
At transvaginal sonography, the adnexal mass of an EP embryo (with or without cardiac activity) [25, 28]. A less strin-
has a wide range of sonographic appearances. In up to 71% gent criterion is the identification of a complex adnexal mass
of patients, an extraovarian adnexal or tubal ring is visible in a patient with a positive pregnancy test result and no

Fig. 3.-Tiny, well-defined fluid collections oc-

casionally seen within endometrium at transvag-
Inal sonography. Cysts may be found In
nonpregnant patients and have been reported In
association with ectopic pregnancies. Small
cysts can resemble early gestational sacs.
A, Longitudinal sonogram of uterus shows small
decidualcyst(an’ow)In 38-year-old nonpregnant pa-
tient undergoing fertility treatment. Calipers depict
thickened endometrium.
B, Longitudinal sonogram of Intrauterine “cyst”
(arrow)In 30-year-old pregnant patient. This “cyst”
evolved into normal intrauterine pregnancy.
 254 FRATES AND LAING AJR:165, August 1995
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Fig. 4.-Transvaginal sonogram in 35-year-old pa- Fig. 5.-Characteristics of tubal ring in Fig. 6.-Complex appearance of adnexal
tient with right-sided pelvic pain, positive pregnancy ectopic pregnancy. Tubal ring of ectopic mass of ectopic pregnancy. With careful imag-
test, and no intrauterine pregnancy. Coronal transvag- pregnancy may have anechoic center or ing, further characterization of mass Is some-
Inal sonogram of right adnexa shows tubal ring of ec- may contain yolk sac or embryo with or times possible. For this 23-year-old patient with
topic pregnancy (arrows). Tubal ring is characterized without cardiac activity. On this transvagi- ectoplc pregnancy, longitudinal transvaginal
by anechoic center and echogenic periphery. Adjacent nal sonogram for 32-year-old patient with sonogram of left adnexa shows elongated, tubu-
normal right ovary (OV) is marked by calipers. ectopic pregnancy, tubal ring of ectopic lar heterogeneous mass (arrows) corresponding
pregnancy is seen, with cardiac activity to hematosalpinx. Free fluid is present around
documented on M-mode tracing. mass. No other adnexal lesions were seen. Com-
plex adnexal mass of any character Is sufficient
to make diagnosis of ectopic pregnancy in at-
risk patients.

Fig. 7.-Improvement of diagnos-

tic sensitivity with careful scanning
technique. Transvaglnal sonogra-
phy IdentifIed large complex adnex-
al mass In 27-year-old patient with
ectopic pregnancy.
A, Sagittal sonogramofleftadnexa
shows large heterogeneous mass
(outlined by calipers).
B, Meticulous scanning of mass
revealed small adnexal ring (arrows)
containing central yolk sac; specific-
ity of diagnosis was increased to
100%.

intrauterine pregnancy. This criterion has a reported sensitiv- identification of any nonsimple, nonovarian adnexal lesion
ity of 21-84% and a specificity of 93-99.5% [25, 28]. The can be used to make a sonographic diagnosis of EP.
most lenient criterion is the identification of free intraperito- In 15-35% of patients with EP, no adnexal mass will be
neal fluid and an empty uterus, with a sensitivity of 63% and identified despite meticulous scanning technique [18, 23, 24,
a specificity of 69% [28]. 28]. In these women, free intraperitoneal fluid may be helpful
In an effort to determine the performance characteristics for suggesting the diagnosis. In morbidly obese patients and
for these multiple criteria, a recent publication combined the in patients with large uterine fibroids or preexisting adnexal
results of 10 previously reported studies [25]. The authors disease, the diagnostic accuracy of sonography can be quite
concluded that for patients with a clinical suspicion of EP, the limited, and negative findings at examination should be inter-
most appropriate diagnostic criterion was the presence of preted with caution [25].
any noncystic, extraovarian adnexal mass. This criterion,
which included living EPs, tubal rings, and complex cystic or
Free Fluid
solid masses, had both a high specificity (98.9%) and a high
positive predictive value (96.3%) as well as acceptable sen- Transvaginal sonography is superior to transabdominal
sitivity (84.4%) and negative predictive value (94.8%). There- sonography for detecting small amounts of free fluid, in part
fore, in the absence of an intrauterine pregnancy, the because the distended bladder required for a transabdominal
 AJR:165, August 1995 SONOGRAPHIC EVALUATION OF ECTOPIC PREGNANCY 255
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examination frequently displaces small quantities of free fluid approximately 95% [25]. Nonetheless, in an at-risk patient
out of the pelvis, rendering it invisible [29]. Bladder decom- population, this statistic should not be considered reassur-
pression and the lithotomy position used for the vaginal ing. In one recent report, four patients with surgically proved
examination allow fluid to descend into the pouch of Dou- EP and fallopian tube rupture had normal sonographic find-
glas. Even a small amount of free fluid in the pelvis may out- ings within 24 hr before surgery [24]. In patients at risk, care-
line the uterus, dilated tubes, ovaries, and any abnormal ful clinical and sonographic monitoring is required until the
pelvic mass, thereby contributing to a superior examination. pregnancy location is established unequivocally.
In patients at risk, any amount of cul-de-sac fluid that is more
than a trace should be considered abnormal. Although the
Role of Doppler Sonography
pelvis is optimally examined by the vaginal approach, the
upper abdomen also should be examined to search for free Recently, color and pulsed Doppler imaging capabilities
fluid in Morison’s pouch and the paracolic gutters. have been added to the vaginal probe. In an effort to improve
Free intraperitoneal fluid is the least specific criterion for the sonographic diagnosis of EP, several different applica-
diagnosing EP. Although it usually accompanies other find- tions for Doppler sonography have been proposed.
ings that suggest the diagnosis, isolated free fluid has been Pulsed Doppler interrogation of the adnexal lesion with cal-
reported in approximately 15% of patients with proved EP culation of the resistive index has been proposed to help dis-
[23, 28]. Causes of intraperitoneal free fluid include active tinguish between a corpus luteum cyst of pregnancy and the
bleeding from the fimbriated end of the fallopian tube, tubal adnexal mass of an EP [31]. However, EPs have a wide range
rupture, and tubal abortion [23, 24, 28]. Occasionally, the of resistive indexes (Fig. 9), and considerable overlap can be
source may be a ruptured corpus luteum cyst. found between the resistive indexes of the EP and the corpus
Although free fluid of any character increases the likeli- luteum. Therefore, the intraovarian location of the corpus
hood of EP, echogenic free fluid is particularly worrisome luteum cyst should be used to differentiate it from an EP [32].
because it suggests a hemoperitoneum [30] (Fig. 8). The Other paraovarian masses may demonstrate a low-resistance
detection of echogenic free fluid, reported in 28-56% of arterial blood flow pattern similar to that of an EP. False-posi-
patients with EP [22, 28], requires optimal equipment set- tive results may be attributable to pelvic inflammation, pedun-
tings. One useful adjustment is to increase the gain control to culated fibroids, or even an exophytic ovarian cyst.
a level that is just beneath introducing artifactual echoes into Despite the enthusiasm of some investigators with regard to
urine within the bladder. Occasionally, clotted blood appears the ability of color Doppler sonography to aid in the diagnosis
as an amorphous echogenic mass(es) separate from the of EP, its usefulness remains unproven. Only a few compara-
adnexal ring of the EP. Alternatively, a hemoperitoneum may tive transvaginal studies that used both gray-scale and color
appear as a completely anechoic fluid collection [28]. Doppler imaging have been reported [32, 33]. Because the
study designs and gray-scale criteria used to diagnose EP

adnexal
#{244}n
results
nass, the
iraphy is

Fig. 9.-Resistive indexes in ectopic pregnancy. Wide range of resis-

tive indexes can be found in ectopic pregnancies with pulsed Doppler in-
nic free flu- terrogation.
is of partic- A, Transvaginal sonogram of adnexal mass obtained by pulsed Dop-
ansvaglnal pier interrogation shows low resistive index (0.37), such as that found in
fluid level some ectopic pregnancies.
sterisk). B, For another patient, high resistive index (0.90) was seen.
 256 FRATES AND LAING AJR:165, August 1995
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varied considerably in these reports, the results are similarly free fluid cannot be considered proof of the absence of tubal
disparate. Often, strict gray-scale criteria were used but loose rupture, as 21% of patients with no fluid or a trace of fluid
diagnostic criteria were chosen for color Doppler imaging, had rupture found at surgery [24].
making comparison ofthe techniques unrealistic. Although the These results suggest that fallopian tube status cannot be
authors reported improved diagnostic results with color Dop- determined sonographically on the basis of adnexal mass
pIer imaging alone, their gray-scale sensitivities were well appearance or presence or amount of free fluid and that
below the 87-94% attained by most investigators [13, 21 23, , transvaginal sonography should not be considered sufficient
25, 34]; the color results therefore appear artificially high. for the characterization of fallopian tube status.
It was hoped that the addition of color Doppler sonography
to gray-scale imaging would improve the sensitivity for EP by Sonographic Findings for Unusual Forms of Ectopic
identifying an extraovarian area of increased vascularity that
Pregnancy
could signal the presence of ectopic trophoblastic tissue
when no mass was visible on gray-scale imaging. However, Interstitial Pregnancies
studies addressing this possibility have been unable to dem-
Interstitial pregnancies account for 2-4% of all EPs but
onstrate an improvement beyond the well-documented high
have significantly higher morbidity and mortality than do
sensitivity of gray-scale imaging alone.
tubal EPs. Interstitial pregnancies occur when the products
Doppler imaging may prove useful in monitoring tropho-
of conception implant within the interstitial or intramural por-
blastic activity and in determining appropriate therapy for
tion of the fallopian tube [26, 47, 48]. In this location, myo-
patients with a visible adnexal mass. It has been suggested
metrium surrounds a portion of the expanding gestational
that absent ectopic trophoblastic flow within a mass on color
sac, allowing it to enlarge painlessly for a relatively long
Doppler interrogation correlates with nonviable tissue [31,
period of time, as compared with a tubal EP. Most patients
35, 36]. Nonsurgical or even expectant management may be
with interstitial pregnancies become acutely symptomatic
suitable in such cases. Additional clinical studies are needed
during the late first or early second trimester, when uterine
to determine the efficacy of this approach.
rupture results in massive hemorrhage. The term cornual
In summary, the use of transvaginal sonography alone for
pregnancy, frequently used interchangeably with interstitial
the diagnosis of EP has proven high sensitivity and specific-
pregnancy, should be reserved for pregnancies within a rudi-
ity. Although Doppler interrogation, if available, may provide
mentary uterine horn [26].
additional information for a limited number of patients, the
Sonographic findings that suggest an interstitial EP
current literature does not support the universal addition of
include an eccentric location of the gestational sac and myo-
color or pulsed Doppler imaging to transvaginal sonography
metrial thinning or absence of myometrium around the sac
for the diagnosis of EP, and Doppler imaging should not be
margins. However, because visible myometrium may com-
considered a necessity.
pletely surround an early interstitial EP [49], the sonographic
diagnosis can be difficult. In an attempt to improve the diag-
Diagnosing Tubal Rupture nostic ability of transvaginal sonography, the interstitial line
Because of an increasing trend toward the medical man- sign has been proposed [48]. This sign is visualized as a thin
agement of a tubal EP [37-43] and because nonsurgical echogenic line that extends from the central uterine cavity
management of a tubal gestation requires an intact tube echo to the periphery of the interstitial gestational sac (Fig.
before and during treatment, an attempt has been made to 1 0). Presumably, the line represents the endometrial canal or
characterize the status of the fallopian tube on the basis of the interstitial portion of the fallopian tube [48]. When used in
sonographic findings. combination with the sonographic findings of an incomplete
Several authors have suggested that an intact fallopian tube mantle and eccentric gestational sac location, the interstitial
can be diagnosed when there is a visible tubal ring, with or line sign may prove to be a useful adjunct for the early diag-
without a yolk sac, embryo, or cardiac activity [22, 23, 34]. nosis of interstitial EP.
However, other authors disagree and have reported that a Conditions that can mimic interstitial EP include a normal
tubal ring can be identified even in the presence of tubal rup- early intrauterine pregnancy that is extremely eccentric in its
ture [44, 45]. A recently published retrospective study of 132 location and an eccentric location of a gestational sac
patients with surgically proved EP found fallopian tube rupture because of a congenital anomaly, such as a uterus subsep-
in 38% of patients with a tubal nng [24]. These authors also tus. In the latter condition, a thin line may be observed
reported that rupture was surgically evident in 21% of patients extending from the endometrial cavity to the periphery of the
without any adnexal mass at transvaginal sonography. sac. However, in patients with this anomaly, the line also
Some reports rely on negative sonographic findings, such extends toward the contralateral uterine horn and is curved
as the absence of a large amount of intraperitoneal fluid, to (Fig. 11), as opposed to the straight line described for a true
infer an intact tube [37, 40, 41, 46]. Although the frequency interstitial EP.
of tubal rupture increases with progressively larger volumes If a question arises during the first trimester for a clinically
of free fluid, up to 37% of patients with a large hemoperito- stable patient, follow-up often can often be useful in precisely
neum may have an intact tube. In addition, the absence of locating the pregnancy.
 AJR:165, August 1995 SONOGRAPHIC EVALUATION OF ECTOPIC PREGNANCY 257
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Fig. 10.-Interstitial ectopic pregnancy. This condition is unusual form of ectopic pregnancy that may be difficult to diagnose at transvaginal sonog-
raphy because visible myometrium may surround entire sac at early gestational age. Interstitial line sign has been proposed as useful in such instances.
For this 29-year-old patient with interstitial pregnancy, coronal sonogram of uterus shows interstitial line (arrow) extending to eccentrically located sac.

Fig. 11.-Similarity between normal and interstitial pregnancies. In presence of congenital uterine anomaly, eccentric location of normal intrauterine
gestational sac may mimic appearance of interstitial pregnancy. Transvaginal coronal sonogram of uterus shows normal but eccentrically located in-
trauterine pregnancy in patient with uterus subseptus anomaly. Note curved configuration of endometrial stripe as it extends toward sac (arrow). This
sign should not be confused with straight interstitial line sign that has been reported for true interstitial pregnancy.

Ceivical Pregnancies differential diagnosis includes a spontaneous abortion in

progress and a large nabothian cyst. In cases of a spontane-
Cervical pregnancies are rare, accounting for approximately
ous abortion, the sac shape and location should change on
0.15% of EPs [50]. Risk factors that predispose a woman to
serial imaging. A nabothian cyst usually can be distinguished
this potentially life-threatening condition include in vitro fertili-
from cervical EP by transvaginal sonography because the cyst
zation [51], prior uterine curettage, fibroids, an indwelling
lacks an echogenic rim, yolk sac, and embryo.
intrauterine device, and previously treated Asherman’s syn-
In the past, cervical pregnancies invariably were treated
drome [26]. The sonographic diagnosis can be made when a
with hysterectomy because of uncontrollable hemorrhage.
well-formed gestational sac that contains a yolk sac, embryo,
With the advent of transvaginal sonography, cervical preg-
or cardiac activity is identified within the cervix (Fig. 12). The
nancies can be diagnosed early in gestation (<7 weeks of
menstrual age) and treated promptly. Local potassium chlo-
ride (KCI) injection [52], systemic methotrexate treatment
[53], or preoperative uterine artery embolization before dila-
tation and evacuation [54] each preserves the uterus and
potentially allows subsequent uterine implantations to occur.
We have used a variety of these options, and sonographi-
cally guided termination with KCI is our procedure of choice
for cervical EP. Transvaginal sonography is used to guide a
needle into the cervical gestational sac for injection of KCI.
Using this technique, we have successfully treated seven of
our last nine patients without complication [52]. Five patients
who have undergone conservative treatment at our institu-
tion subsequently have been able to conceive successfully.
When the diagnosis of cervical EP is made, conservative
treatment has proved effective.

Fig. 12.-Cervicalectopic pregnancy. When diagnosis ofthis rare form of Role of Sonography in Treatment
ectopic pregnancy is made at early gestational age by transvaginal sonogra-
phy, early intervention may prevent life-threatening hemorrhage. In this 37- With the combination of sensitive and specific pregnancy
year-old patient with vaginal bleeding, longitudinal transvaginal sonogram tests and high-resolution transvaginal sonography, the diag-
of uterus shows gestational sac (cuivedarrows) with yolk sac within cervix.
Cardiac activity was documented by M-mode tracing (not shown). Normal nosis of EP now can be made earlier and with more confi-
endometnal stripe Is visible in body of uterus (straight arrows). dence. These improvements allow prompt intervention,
 258 FRATES AND LAING AJR:165, August 1995
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which for most patients remains surgical. However, alterna- 10. Rizk B, Tan SL, Morcos S, et al. Heterotopic pregnancies after in vitro fer-
tilization and embryo transfer. Am J Obstet Gyneco/1991;164:161-164
tive medical therapeutic options are becoming increasingly
11. Goldman GA, Fisch B, Ovadia J, Tadir V. Heterotopic pregnancy after
available. These medical regimens most often use the che-
assisted reproductive technologies. Obstet Gynecol Surv 1992;47:21 7-221
motherapeutic agent methotrexate, administered systemi- 12. Derman R. Early diagnosis of pregnancy: a symposium. J Reprod Med
cally or directly into the ectopic sac or hematosalpinx under 198126:149
sonographic or direct laparoscopic guidance. When medical 13. Cacciatore B, Stenman UH, Ylostalo P. Diagnosis of ectopic pregnancy by
vaginal ultrasonography in combination with a discriminatory serum hCG
treatment is chosen, transvaginal sonography allows moni-
level of 1000 lU/I [lAP]. BrJ Obstet Gynaecol 1990;97:904-908
toring of the adnexal mass and evaluation of potential corn- 14. Levi CS, Lyons EA, Lindsay DJ. Early diagnosis of nonviable pregnancy
plications both during and after therapy. with endovaginal US. Radiology 1988;167:383-385
Following systemic or intratubular methotrexate therapy, a 15. Nyberg DA, Laing FC, Filly RA, Un-Simmons M, Jeffrey RB. Ultrasono-
visible adnexal mass may persist on transvaginal sonogra- graphic differentiation of the gestational sac of early intrauterine preg-
nancy from the pseudogestational sac of ectopic pregnancy. Radiology
phy for more than 3 months, even after the -hCG test
1983;146:755-759
becomes negative. It is also not uncommon for the mass to 16. Yeh HC, Goodman JD, Carr L, Rabinowitz JG. Intradecidual sign: a US
transiently enlarge and have increased Doppler flow signals criterion of early intrauterine pregnancy. Radiology 1986;161 :463-467
[39, 46]. Complications of sonographically guided methotrex- 17. Laing FC. Ectopic pregnancy. In: Taveras JM, Ferrucci JT, eds. Radiology:
diagnosis-imaging-intervention, vol. 4. Gastrointestinal/abdominal and
ate injection include an acute hemoperitoneum and pain
pelvic/genitourinary. Philadelphia: Lippincott, 1993; ch.87A:1-1O
requiring rehospitalization [55]. In up to one third of cases, 3- 18. Russel SA, Filly RA, Damato N. Sonographic diagnosis of ectopic preg-
hCG levels continue to rise and additional injections of sys- nancy with endovaginal probes: what really has changed? J Ultrasound
ternic methotrexate are required [55]. Med 1993;3:145-151
19. Ackerman TE, Levi CS, Lyons EA, et al. Decidual cyst: endovaginal sono-
Perhaps the most controversial area of EP treatment is
graphic sign of ectopic pregnancy. Radiology 1993;189:727-731
expectant management. In two small series, asymptomatic 20. Droegemueller W. Ectopic pregnancy. In Danforth DN, ed. Obstetrics and
women with declining or stable -hCG levels and small adnexal gynecology, 4th ed. Philadelphia: Harper & Row, 1982:407-409
masses at transvaginal sonography were monitored without 21 . Rempen A. vaginal sonography in ectopic pregnancy. J Ultrasound Med
intervention. In these carefully selected patients, representing 1988;7:381-387
22. Fleischer AC, Pennel RG, Mckee MS, et al. Ectopic pregnancy: features
approximately one quarter of all patients with EP seen in their
at transvaginal sonography. Radiology 1 990; 174:375-378
respective institutions, repeated transvaginal sonography, 3- 23. Rottem 5, Thaler I, T,mov-Tritsch IE. Classification of tubal gestations by
hCG level determinations, and close clinical monitoring con- transvaginal sonography. Ultrasound Obstet Gynecol 1991 1:197-201
firmed a successful outcome in 69% [40] and 100% [41] of 24. Frates MC, Brown DL, Doubilet PM, Homstein MD. Tubal rupture in

cases. Not surprisingly, the safety and efficacy of this manage- patients with ectopic pregnancy: diagnosis with transvaginal US. Radiol-
ogy 1994;191 :769-772
ment option have been questioned [56]. 25. Brown DL, Doubilet PM. Transvaginal sonography for diagnosing ectopic
pregnancy: positivity criteria and performance characteristics. J Ultra-
sound Med 1994:13:259-266
Conclusion 26. Fredericks CM, Hotz G. Nontubal ectopic pregnancy. In Fredericks CM,
Paulson JD, Holtz G, ed. Ectopicpregnancy. New York: Hemisphere Pub-
With the introduction of transvaginal sonography, the diag-
lishing, 1989:193-206
nosis of EP has changed dramatically. EP can be diagnosed
27. Berry SM, Coulam CB, Hill LM, Breckle R. Evidence of contralateral ovu-
earlier and with more confidence than before. Transvaginal lation in ectopic pregnancy. J Ultrasound Med 1985;4:293-295
sonography remains at the forefront for the evaluation of 28. Nyberg DA, Hughes MP, Mack LA, Wang KY. Extrauterine findings of
patients with suspected EP. ectopic pregnancy at transvaginal US: importance of echogenic fluid.
Radiology 1991 ; 178:823-826
29. Nyberg DA, Laing FC, Jeffrey RB. Sonographic detection of subtle pelvic
REFERENCES fluid collections. AJR 1984;143:261-263
30. Jeffrey RB, Laing FC. Echogenic clot: a useful sign of pelvic hemoperito-
1 . Centers for Disease Control. Ectopic pregnancy-United States, 1988- neum. Radiology 1 982; 145:139-141
1989. Morbid Mortal Weekly Rep 1992;41 :591-594 31 . Kurjack A, Zalud I, Schulman H. Ectopic pregnancy: transvaginal color
2. Schwartz RO, Di Pietro DL. B-hCG as a diagnostic aid for suspected Doppler of trophoblastic flow in questionable adnexa. J Ultrasound Med
ectopic pregnancy. Obstet Gynecol 1980;56:197-203 199110:685-689
3. Dashefsky SM, Lyons EA, Levi CS, Lindsay DJ. Suspected EP: endovagi- 32. Pellerito JS, Taylor KJW, Quedens-Case C, et al. Ectopic pregnancy: eval-
nal and transvesical US. Radiology 1988;169:181-184 uation with endovaginal color flow imaging. Radiology 1992;183:407-411
4. Nyberg DA, Mack LA, Jeffrey RB, Laing FC. Endovaginal sonographic 33. Emerson DS, Cartier MS, Altien LA, et al. Diagnostic efficacy of endovag-
evaluation of ectopic pregnancy: a prospective study. AJR 1987:149: inal color Doppler flow imaging in an ectopic pregnancy screening pro-
1181-1186 gram. Radiology 1992;183:413-420
5. Timor-Tritsch IE, Yeh MN, Peisner DB, Lesser KB, Slavik TA. The use of 34. Cacciatore B. Can the status of tubal pregnancy be predicted with trans-
transvaginal ultrasonography in the diagnosis of ectopic pregnancy. Am J vaginal sonography? A prospective comparison of sonographic, surgical
Obstet Gynecol 1989;161 :157-161 and serum hCG findings. Radiology 199Q177:481-484
6. Thorsen MK, Lawson TL, Aimain EJ, et al. Diagnosis of EP: endovaginal 35. Tekay A, Jouppila P. Color Doppler flow as an indicator of trophoblastic
vs. transabdominal sonography. AJR 1990;155:307-310 activity in tubal pregnancies detected by transvaginal ultrasound. Obstet
7. Cacciatore B, Stenman UH, Ylostalo P. Comparison of abdominal and Gynecol 1992:80:995-999
vaginal sonography in suspected ectopic pregnancy. Obstet Gynecol 36. Taylor KJW, Ramos IM, Feyock AL, et al. Ectopic pregnancy: duplex Dop-
1 989;73:770-774 pIer evaluation. Radiology 1 989;1 73:93-97
8. Kivikoski Al, Martin CM, Smeltzer JS. Transabdominal and transvaginal 37. Stovall TG, Ling FW, Gray LA, Carson SA, Buster JE. Methotrexate treat-
ultrasonography in the diagnosis of ectopic pregnancy: a comparative ment of unruptured ectopic pregnancy: a report of 100 cases. Obstet
study. Am J Obstet Gynecol 1990; 163:123-128 Gynecol 199177:749-753
9. Hann LE, Bachman DM, McArdle CR. Coexistent intrauterine and ectopic 38. Stovall TG, Ling FW, Gray LA. Single-dose methotrexate for treatment of
pregnancy: a reevaluation. Radiology 1984;152:151-154 ectopic pregnancy. Obstet Gynecol 199177:754-757
 AJR:165, August 1995 SONOGRAPHIC EVALUATION OF ECTOPIC PREGNANCY 259
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39. Brown DL, Felker RE, Stovall TG, Emerson DS, Ling FW. Serial endovag- 48. Ackerman TE, Levi CS, Dashefsky SM, Holt SC, Lindsay DJ. Interstitial
inal sonography of ectopic pregnancies treated with methotrexate. Obstet line: sonographic finding in interstitial [comual] ectopic pregnancy. Radiol-
Gynecol 1991 ;77:406-409 ogy 1993;189:83-87
40. Ykstalo P, Cacciatore B, Sjoberg J, Kaandnen M, Tenhunen A, Stenman UH. 49. Beckmann CR6, Sampson MB. Ultrasonographic diagnosis of interstitial
Expectant managementofectopic pregnancy. stetGyneco/1992;80:345-348 ectopic pregnancy. J Clin Ultrasound 1984;12:304-306
41 . Atri M, Bret PM, Tulandi T. Spontaneous resolution of ectopic pregnancy: 50. Jones HW Ill, Cobton AC, Brunett LS. Novak’s textbook of gynecology,
initial appearance and evolution at transvaginal US. Radiology 1993; 11th ed. Baltimore: Williams & Wilkins, 1988:499
186:83-86 51 . Ginsburg ES, Frates MC, Rein MS, Fox J, Hornstein M, Friedman AJ.
42. Carson SA, Buster JE. Ectopic pregnancy. N EngI J Med 1993;329: Early diagnosis and treatment of cervical pregnancy in an in vitro fertiliza-
1174-1179 tion program. Fertil Ster111994;61 :966-969
43. Ory SJ. New options for diagnosis and treatment of ectopic pregnancy. 52. Frates MC, Benson CB, Doubilet PM, et al. Cervical ectopic pregnancy:
JAMA 1992;267:534-537 results of conservative treatment. Radiology 1994;191:773-775
44. Laing FC. Sonographic determination of tubal rupture in patients with 53. Stovall TG, Ling FW, Smith WC, et al. Successful nonsurgical treatment of
ectopic pregnancy: is it feasible? Radiology 1990;177:330-331 cervical pregnancy with methotrexate. FertilSterill988;50:672-674
45. Atri M, deStempel J, Bret PM. Accuracy of transvaginal ultrasonography 54. Meyerovitz MF, Lobel SM, Harrington DP, Bengston JM. Preoperative
for detection of hematosalpinx in ectopic pregnancy. J Clin Ultrasound uterine artery embolization in cervical pregnancy. J Vasc Intent Radiol
1992;20:255-261 19912:95-97
46. Atn M, Bret BM, Tulandi T, Senterman MK. Ectopic pregnancy: evolution after 55. Fernandez H, Benifla JL, Lelaidier C, Baton C, Frydman R. Methotrexate
treatment with transvaginal methotrexate. Radiology 1992;185:749-753 treatment of ectopic pregnancy: 100 cases treated by primary transvagi-
47. Timor-Tritsch IE, Monteagudo A, Matera C, veit CR. Sonographic evolu- nal injection under sonographic control. FertllSterill993;59:773-777
tion of cornual pregnancies treated without surgery. Obstet Gynecol 56. Zacur HA. Expectant management of ectopic pregnancy. Radiology
1992;79:1044-1049 1993;186:11-12